Ahmad Amin

Serum Uric Acid Levels Correlate With Filling Pressures in Systolic Heart Failure

The authors studied the relationship between liver function tests and serum uric acid level with clinical and hemodynamic profiles in heart failure. Fifty patients (aged 44±15 years; 74.5% men) with an ejection fraction (EF) <35% were enrolled and clinical assessment was performed. Hemodynamic indices (including pulmonary arterial pressure [PAP], pulmonary capillary wedge pressure [PCWP], and cardiac index were studied by standard Edwards Lifesciences Swan-Ganz catheters, and liver function tests and serum uric acid level were measured simultaneously. Fifty age- and sex-matched controls with normal EF were also studied. A total of 73% of patients had ischemic cardiomyopathy. Mean uric acid level was 7.2±3.8 mg/dL and was significantly higher than in the control group (P value<.001). In multivariate analysis, uric acid correlated significantly with PAP (r=.5, P<.001) and PCWP (r=.4, P=.002) and was also associated with clinical signs of rales, edema, paroxysmal nocturnal dyspnea (r=.5, P=.01), and New York Heart Association class (r=.4, P=.005). Uric acid level was also correlated inversely with left ventricular EF (r=.27, P=.006). Elevated uric acid levels in patients with systolic heart failure is associated with impaired clinical and hemodynamic profile and might be used as a noninvasive indicator of elevated left ventricular filling pressures.

Muscle wasting in young patients with dilated cardiomyopathy

Muscle wasting can be accelerated by chronic diseases such as heart failure and is one of the major causes of disability, morbidity, and mortality in this population. We aimed to investigate the incidence of muscle wasting and its associated factors in dilated cardiomyopathy patients younger than 55 years of age.

On admission serum sodium and uric acid levels predict 30 day rehospitalization or death in patients with acute decompensated heart failure

A considerable proportion of hospitalized patients for acute decompensated heart failure will be readmitted or die in short‐term follow‐up. In the present study, we aimed to assess the role of admission sodium (Na) and uric acid (UA) levels in the prediction of 30 day post‐discharge heart failure readmission or all‐cause mortality in advanced heart failure patients admitted with acute decompensation.

Insulin Resistance in Pulmonary Arterial Hypertension, Is It a Novel Disease Modifier?

Background: Recent studies have introduced glucose intolerance and insulin resistance (IR) as novel risk factors in patients with pulmonary arterial hypertension (PAH). Objectives: We aimed to investigate the prevalence of glucose intolerance and IR in patients with PAH and their correlation with functional capacity and prognostic factors. Patients and Methods: Sixty-nine patients with pulmonary arterial hypertension (class I Pulmonary hypertension in accordance with updated clinical classification of pulmonary hypertension) scheduled for right heart catheterization were enrolled. FBS, HbA1c, lipid profile, pro –BNP and hs-CRP were measured along with a 6-minute walk test (6-MWT) and obtaining demographic, functional and hemodynamic data. Fasting triglyceride to high-density lipoprotein cholesterol ratio (TG/HDL-C) was used as a surrogate of insulin sensitivity. Using published criteria, HbA1c ≤ 5.9% defined as normal, 6.0-6.4% as glucose intolerance, and ≥ 6.5% as diabetes. All patients were followed for a year regarding development of any cardiovascular event (mortality and/or hospitalization). Results: In total, 76.8% of patients were female: 61% of them had idiopathic PAH, 33% Eisenmenger syndrome, and 6% PAH secondary to a connective tissue disease. With respect to TG/HDL-C, 43.5% of patients had IR and 47.8% of patients had HbA1c > 6. There was no difference between IR and insulin sensitive (IS) group or glucose intolerance and sensitive group regarding NYHA class, 6MWT, Pro BNP, hs-CRP and hemodynamic data and there was no correlation between IR or glucose intolerance and any event. Conclusions: Unrecognized glucose intolerance and IR are common in PAH. However, further studies are needed to show whether glucose or insulin dysregulation plays any role in PAH pathogenesis or it is secondary to advanced PAH.

Hormonal Profile in Patients With Dilated Cardiomyopathy

Background: There is increasing evidence that endocrine system may be dysfunctional in patients with heart failure. Objectives: In the present study, we investigated hormonal abnormalities in heart failure and the effect of disturbed hormonal balance on prognostic outcomes of patients with systolic heart failure. Patients and Methods: Among patients followed in Heart Failure and Transplantation Clinic, 33 men with a diagnosis of idiopathic dilated cardiomyopathy receiving guidelines-directed medical therapies and with New York Heart Association Class II-III were enrolled. Serum concentrations of growth hormone (GH), insulin-like growth factor 1 (IGF-1), thyroid hormones, free testosterone, high-sensitive C-reactive protein (hs-CRP), and N-terminal pro-brain natriuretic peptide (NT Pro-BNP) were measured in all the patients. The physical performance of patients was assessed by six-minute walk test (6MWT). The patients were subsequently followed for a year and the data regarding their death, transplantation, or hospitalizations due to acute heart failure were recorded. Results: Except for testosterone level, the levels of GH, IGF-1, T3, and T4 concentrations in the patients were significantly lower than the normal values (P < 0.05). Among different hormone, only GH had correlation with NT Pro-BNP, hs-CRP, and 6MWT. There was no association between the occurrence of the combined events and different hormonal levels in multivariate analysis. Conclusions: The hormonal levels were low in patients with idiopathic dilated cardiomyopathy. However, the prognostic significance of different hormonal deficiencies was not clear in our study populations who were receiving standard therapies for heart failure and had a relatively stable clinical condition.

Evaluation of Left Atrial Two-Dimensional Strain in Patients with Systolic Heart Failure using Velocity Vector Imaging

Background: Two-dimensional (2D) Strain is a new reproducible technique for assessing regional myocardial function; however, its application for evaluation of left atrium (LA) function is less studied. Objectives: We sought to assess LA function in heart failure patients using velocity vector imaging (VVI). Patients and Methods: Thirty five patients (mean age: 43.34 ± 18.1 years, 59.3% male) with systolic dysfunction [left ventricle ejection fraction (LVEF) < 35%] enrolled. Standard Doppler echocardiography and 2D strain were performed on all subjects. Strain measurements were obtained from apical views. Results: A significant differences in LA volume index (LAVI) and strain were found in patients with systolic heart failure (SHF) versus normal subjects (23.8 ± 4.1 versus 57.8 ± 19.7 ml/m2, P < 0.001 and 39.6 ± 10.6 versus 8.2 ± 5.3%, P < 0.001). Multivariate analysis of separate walls revealed significant inverse relationship between LA size and volume with total and regional (2-ch view) 2D strains of LA. Significant inverse relationship were also detected between pulmonary artery systolic pressure and both total LA strain (22 ± 8 versus 42 ± 10 mmHg, r = -0.4, P < 0.001) and LA strain in 2-chamber (r = -0.5, P < 0.001). A cutoff value of total average LA strain (≥ 23.28%) can differentiate normal and abnormal LA function with a sensitivity of 93% and specificity of 100% and a cutoff value of total LA strain (in average) of 17.2% can differentiate mild and moderate and severe diastolic dysfunction with a sensitivity of 100% and a specificity of 97%. Conclusions: LA strain seems to be a better determinant for diagnosis of abnormal LA function and the degree of diastolic dysfunction in SHF.

Development and Validation of the First Iranian Questionnaire to Assess Quality of Life in Patients With Heart Failure: IHF-QoL

Background: In its Constitution of 1948, WHO defined health as “a state of complete physical, mental, and social well-being, and not merely the absence of disease and infirmity” . In 1994, the Agency for Health Care Policy and Research published clinical practice guidelines recommending providers to routinely evaluate patients’ HRQoL (Health Related Quality of Life) and use their assessment to modify and guide patient care. Objectives: to create a valid, sensitive, disease-specific Persian health status quality of life questionnaire for patients with chronic heart failure in Iran. Materials and Methods: Considering the existing relevant inventories and scientific literature, the authors designed the first draft of questionnaire which was modified and validated, using expert opinions and finalized in a session of expert panel. The questionnaire was processed among 130 patients with heart failure. Construct validity evaluated by principle component factor analysis, and promax method was used for factor rotation. MacNew quality of life questionnaire was selected to assess convergence validity, and the agreements were measured in 60 patients. Discriminant validity was also assessed. Thirty patients were followed for 3 months and responsiveness of questionnaire was measured. Cronbachs alpha, item analysis, and Intra-class correlation coefficients (ICCs) were used to investigate reliability of questionnaire. SPSS 15 for Windows was applied for statistical analysis. Results: Principle component factor analysis revealed 4 main components. Sub-group analysis suggested that IHF-QoL questionnaire demonstrated an acceptable discriminant validity. High conformity between this inventory and MacNew questionnaire revealed an appropriate convergence validity. Cronbachs alpha (α) for the overall questionnaire was equal to 0.922. Intra-class correlation coefficients (ICCs) for all components were significant (from. 708 to. 883; all P values < 0.001). Patients fallow-up revealed an acceptable responsiveness of our questionnaire. Conclusions: IHF-QoL questionnaire is a valid and reliable inventory. It can be applied in daily clinical practice and in the clinical research context.

Pulmonary Arterial Elastance for Estimating Right Ventricular Afterload in Systolic Heart Failure

Assessment of right ventricular afterload in systolic heart failure seems mandatory as it plays an important role in predicting outcome. The purpose of this study is to estimate pulmonary vascular elastance as a reliable surrogate for right ventricular afterload in systolic heart failure. Forty-two patients with systolic heart failure (ejection fraction <35%) were studied by right heart catheterization. Pulmonary arterial elastance was calculated with three methods: Ea(PV) = (end-systolic pulmonary arterial pressure)/stroke volume; Ea*(PV) = (mean pulmonary arterial pressure - pulmonary capillary wedge pressure)/stroke volume; and PPSV = pulmonary arterial pulse pressure (systolic - diastolic)/stroke volume. These measures were compared with pulmonary vascular resistance ([mean pulmonary arterial pressure - pulmonary capillary wedge pressure]/CO). All estimates of pulmonary vascular elastance were significantly correlated with pulmonary vascular resistance (r=0.772, 0.569, and 0.935 for Ea(PV), Ea*(PV), and PPSV, respectively; P <.001). Pulmonary vascular elastance can easily be estimated by routine right heart catheterization in systolic heart failure and seems promising in assessment of right ventricular afterload.

Changes of High Sensitivity C-Reactive Protein During Clopidogrel Therapy in Patients Undergoing Percutaneous Coronary Intervention

Background: The crucial role of inflammation in the development and progression of atherosclerosis has been previously described. However, there is insufficient data available to demonstrate the changes in high sensitivity C-reactive protein (hs-CRP) during clopidogrel therapy. Objectives: In the present study, we aimed to assess the changes in the inflammatory marker of coronary heart disease, i.e., hs-CRP during clopidogrel therapy, in patients undergoing percutaneous coronary intervention (PCI). We also evaluated the anti-inflammatory effects of clopidogrel, if any, in different groups of patients. Patients and Methods: The study population included 650 consecutive patients who underwent elective, urgent, or emergent PCI. Patients received a 300-mg loading dose of clopidogrel (Plavix®) and aspirin either 24 hours before the planned PCI, or immediately before the procedure in patients with urgent or emergent PCI, followed by a 75-mg daily maintenance dose for up to 12 weeks. At the end of the 12th week, hs-CRP was re-assessed. Results: Six hundred-fifty patients including 386 (59.4%) male and 264 (40.6%) female subjects were enrolled in the study. The mean hs-CRP level was 15.36 ± 9.83 mg/L with a median of 14 mg/L (interquartile range 8 to 19.6 mg/L). Female, hypertensive, diabetic, and non-smoking patients had higher reductions in hs-CRP in response to clopidogrel therapy compared to male, non-hypertensive, non-diabetic and smoker patients, respectively (all P < 0.005). The changes in the hs-CRP levels were also statistically different in patients with various index events before PCI (P < 0.001). No significant differences were observed in the mean reduction of hs-CRP between the patients without stent implantation and those with bare metal or drug-eluting stents (P = 0.07), respectively. Conclusions: We found that the use of clopidogrel in patients undergoing PCI had favorable effects on the suppression of hs-CRP. This effect appears to be heightened and more apparent in some group of patients with co-morbidities such as diabetes and hypertension.

LOWER DOSES OF BOSENTAN IN COMBINATION WITH SILDENAFIL MIGHT BE BENEFICIAL IN PULMONARY ARTERIAL HYPERTENSION

Background: Endothelin-receptor-antagonist, bosentan, has been found to improve the functional capacity and cardiopulmonary hemodynamics in Pulmonary Arterial Hypertension (PAH). Clinical trials have shown the preferable dosage of 125 mg, twice daily, regarding both efficacy and safety. Objectives: The purpose of this study was to investigate the effects of lower doses of bosentan (62.5 mg, twice daily) in combination with sildenafil on exercise capacity and clinical events, in 41 patients with idiopathic pulmonary hypertension or chronic thromboembolic pulmonary hypertension (CTEPH). Patients and Methods: We assigned 41 patients with PAH (non-reactive idiopathic or non-operable chronic thromboembolic) to receive 62.5 mg of bosentan twice daily as combination therapy and evaluated the New York heart association (NYHA) functional class, 6-minutes- walk-distance (6MWD), time to clinical worsening, echocardiographic indexes and clinical events, for an average of 18.5 ± 9.5 months. Results: No adverse drug reaction was observed during the follow-up. Clinical worsening occurred in six (14%) patients, at least one year after treatment, two of the cases failed to respond to 125 mg, twice daily and died. Eight (19%) remained in FC I II, but didn’t reach the goal of 380 meters for 6MWD. All other patients reached the treatment goals according to the latest European society of cardiology (ESC) guidelines. Conclusions: We observed acceptable results regarding both efficacy and safety with 62.5 mg of bosentan, twice daily in this group of patients. Further clinical trials investigating PAH with lower dosages of bosentan may be warranted.